<p> Client Health History Form</p><p>The Skin Firm Personal Information:</p><p>Name: ______Date:______</p><p>Email: ______Date of Birth:______</p><p>Address:______</p><p>City: ______State: ______Zip code:______</p><p>Home Phone: ______Cell phone: ______</p><p>Occupation:______</p><p>Emergency contact: ______Phone: ______</p><p>1. Do you have any health problems or concerns that I need to be aware of before treatment? ______Yes ______No</p><p>If the answer is yes, please describe? ______</p><p>2. Do you have any allergies? ______Yes ______No </p><p>If yes, list them ______</p><p>3. Any recent surgery on your face, neck, and shoulders? ______Yes ______No</p><p>4. Are you currently, or have you used Retin-A, Renova, Resorcinol, or any powerful alpha hydroxyl acids within the past 3 months? _____ Yes _____ No</p><p>5. Are currently using or taking Accutane? _____ Yes _____ No</p><p>6. Are you using any other skin thinning products or drugs? _____ Yes _____ No</p><p>The Skin Firm 9140 North Freeway, Ste 300 Studio 23 Fort Worth, TX 76177 (817) 500-4248 7. Are you a diabetic? _____ Yes _____ No</p><p>8. Do you use a tanning bed? _____ Yes _____ No</p><p>9. Are you exposed to the sun daily or will you spend more time out in the sun anytime soon? _____ Yes _____ No</p><p>10. Do you currently wear contact lenses? _____ Yes _____ No</p><p>11. Have you experienced Botox, Restylane or Collagen injections? _____ Yes _____ No If yes please specify? ______</p><p>12. Please circle the following conditions you currently have or have experienced?</p><p>Pacemaker or pins in bones Metal plate Cold sores Warts Lupus High/Low blood pressure Cancer Anemia Epilepsy Hepatitis Asthma Seizures Stroke Headaches Pregnancy Easy bruising Skin infections </p><p>13. Have you ever had an allergic reaction to any of the following:</p><p>Aspirin or Salicylates Yes ____ No ____</p><p>Milk Yes ____ No ____</p><p>Citrus Yes ____ No ____</p><p>Grapes Yes ____ No ____</p><p>Lavender Yes ____ No_____</p><p>Fish, marine or iodine allergies Yes____ No ____</p><p>Cosmetic product Yes ____ No ____</p><p>Skincare products Yes____ No ____</p><p>Nuts/peanuts Yes ____ No ____</p><p>The Skin Firm 9140 North Freeway, Ste 300 Studio 23 Fort Worth, TX 76177 (817) 500-4248 If you checked yes to any of the above, please explain ______</p><p>14. Are you under the care of a Dermatologist? ______</p><p>15. What are your skin concerns and challenges? ______</p><p>I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosure. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release the esthetician from liability and assume full responsibility thereof.</p><p>Client Name ______Date ______</p><p>Guardian Name ______Date ______(If under 18 years of age) Esthetician Name ______Date ______</p><p>The Skin Firm 9140 North Freeway, Ste 300 Studio 23 Fort Worth, TX 76177 (817) 500-4248</p>